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Magen E, Merzon E, Green I, Golan-Cohen A, Magen I, Vinker S, Israel A. A case-control study for comorbidity and laboratory factors associated with food-induced anaphylaxis. Allergy Asthma Proc 2024; 45:53-60. [PMID: 38151728 DOI: 10.2500/aap.2024.45.230076] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Background: Food-induced anaphylaxis (FIA) is a serious and potentially life-threatening allergic reaction triggered by food allergens. Objective: This case-control study aimed to investigate comorbidities and laboratory factors associated with FIA in the pediatric population of Israel. Methods: Retrospective data from the electronic health records of Leumit Health Care Services were used to identify 711 pediatric patients with FIA and 2560 subjects with food allergy and without anaphylaxis matched for age, gender, and ethnicity. Comorbidities were identified based on medical billing diagnosis codes, and laboratory characteristics were compared between the two groups. Results: The mean ± standard deviation age of patients with FIA was 4.1 ± 4.1 years, and 37.3% were girls. Laboratory analysis revealed increased eosinophil counts (p < 0.001), elevated immunoglobulin E (IgE) (p < 0.001), and IgA levels (p = 0.001) in the FIA group compared with the controls. With regard to comorbidities, the FIA group had higher prevalence rates of allergic diseases, including allergic rhinitis (odds ratio [OR] 1.72; p < 0.001), allergic conjunctivitis (OR 1.84; p = 0.001), asthma (OR 1.36; p < 0.001), angioedema (OR 6.37; p < 0.001), atopic dermatitis (OR 1.77; p < 0.001), and contact dermatitis (OR 1.42; p = 0.001). There was a trend toward significance for chronic spontaneous urticaria (p = 0.051). There was a significant negative association between helminthiases, particularly enterobiasis, and FIA (OR 0.76 [95% confidence interval, 0.59-0.98]; p = 0.029). Conclusion: This study provides valuable epidemiologic evidence on the associations among FIA, comorbidities, and laboratory factors in the pediatric population.
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Affiliation(s)
- Eli Magen
- From the Leumit Health Services, Tel Aviv-Yafo, Israel
| | - Eugene Merzon
- From the Leumit Health Services, Tel Aviv-Yafo, Israel
| | - Ilan Green
- From the Leumit Health Services, Tel Aviv-Yafo, Israel
| | | | - Israel Magen
- Medicine A Department, Assuta Ashdod University Hospital Faculty of Health Sciences, Ben-Gurion University, Beer-Sheba, Israel
| | - Shlomo Vinker
- From the Leumit Health Services, Tel Aviv-Yafo, Israel
| | - Ariel Israel
- From the Leumit Health Services, Tel Aviv-Yafo, Israel
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2
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Olabarri M, Sanz N, Gonzalez-Peris S, Vazquez P, Gonzalez-Posada A, Diez N, Vinuesa A, Benito J, Mintegi S. Characteristics of Pediatric Emergency Department Presentations of Anaphylaxis in Spain. Pediatr Emerg Care 2023; 39:755-759. [PMID: 37650818 DOI: 10.1097/pec.0000000000003039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
OBJECTIVE This study aimed to identify the triggers of pediatric anaphylaxis in Spain and to analyze the circumstances of the episode. METHODS Planned secondary analysis of a prospective observational multicenter study endorsed by the Spanish Society of Pediatric Emergencies including children aged younger than 18 years diagnosed with anaphylaxis in 7 Spanish pediatric emergency departments (EDs) between 2016 and 2018. We analyzed factors related to the anaphylaxis episode and its management. RESULTS Four hundred fifty-three cases were registered, happening mainly at home (295 [65.1%]), school (65 [14.3%]), and street (61 [13.5%]). The median age was 5 years, 143 (31.6%) had previous episodes, and 165 (36.4%) had previously been prescribed an epinephrine autoinjector, used in 40 (24.2% of those prescribed). Two thirds were well-appearing when arriving to the pediatric ED. Food was the trigger in 396 (87.4%). In 349 with a single food involved, the most frequent were milk (108 [30.4%]), nuts (103 [29.0%]), hen's egg (40 [11.3%]), and fish (31 [8.7%]), with variations related to the age of the child. CONCLUSIONS Food, especially milk and nuts, are responsible for most anaphylaxis diagnosed in Spanish pediatric EDs. Consideration should be given to improving health education due to the low use of epinephrine autoinjectors.
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Affiliation(s)
- Mikel Olabarri
- From the Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces. University of the Basque Country, UPV/EHU. Bilbao, Basque Country, Spain
| | - Nuria Sanz
- Pediatric Emergency Department, Sant Joan de Déu Hospital, Barcelona, Spain
| | | | - Paula Vazquez
- Pediatric Emergency Department, Gregorio Marañón University Hospital, Madrid, Spain
| | | | - Nuria Diez
- Department of Pediatrics, Río Hortega University Hospital, Valladolid, Spain
| | - Ana Vinuesa
- Department of Pediatrics, Basurto University Hospital - Basque Country University, Bilbao, Spain
| | - Javier Benito
- From the Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces. University of the Basque Country, UPV/EHU. Bilbao, Basque Country, Spain
| | - Santiago Mintegi
- From the Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces. University of the Basque Country, UPV/EHU. Bilbao, Basque Country, Spain
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Bartra J, Turner PJ, Muñoz-Cano RM. Cofactors in food anaphylaxis in adults. Ann Allergy Asthma Immunol 2023; 130:733-740. [PMID: 36958469 DOI: 10.1016/j.anai.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/25/2023]
Abstract
Around 25% to 50% of food-induced allergic reactions in adults cause anaphylaxis, and epidemiologic evidence suggests that food is the most common cause of anaphylaxis. Reaction severity is unpredictable, and patients will often experience reactions of variable severity, even to an identical exposure (both dose and allergen). A common explanation for this phenomenon has been the impact of "cofactors"-factors that might contribute to reaction severity independent of the allergen exposure. Cofactors can influence reaction severity in 2 ways: either by reducing the reaction threshold (ie, the dose needed to trigger any symptoms) so that patients have no symptoms in the absence of the cofactor and only react with the cofactor present, or by increasing reaction severity such that individuals have only mild symptoms in the absence of the cofactor, but a more severe reaction when the cofactor is present. Indeed, the same patient may have reactions with different cofactors or even need more than one cofactor to develop a severe reaction. Cofactors reportedly play a role in approximately 30% of anaphylaxis reactions in adults. Exercise, nonsteroidal, anti-inflammatory drugs, alcohol, and sleep deprivation are the most frequent cofactors reported. Routine evaluation of the possible involvement of cofactors is essential in managing patients with food anaphylaxis: in patients with a suggestive history but a negative oral food challenge, cofactors should be taken into account to provide appropriate advice to reduce the risk of future anaphylaxis.
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Affiliation(s)
- Joan Bartra
- Department of Allergy, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), RETIC ARADyAL, RICORs REI, Barcelona, Spain
| | - Paul J Turner
- National Heart and Lung Institute, Imperial College London, London, United Kingdom.
| | - Rosa M Muñoz-Cano
- Department of Allergy, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), RETIC ARADyAL, RICORs REI, Barcelona, Spain
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Lloyd M, Loke P, Mack DP, Sicherer SH, Perkin MR, Boyle R, Yin Leung AS, Lee BW, Levin M, Blumchen K, Fiocchi A, Ebisawa M, Oliveira LCLD, Tang MLK. Varying Approaches to Management of IgE-Mediated Food Allergy in Children Around the World. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1010-1027.e6. [PMID: 36805346 DOI: 10.1016/j.jaip.2023.01.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 02/17/2023]
Abstract
Food allergy is a chronic disease that affects individuals of all ages and is a significant public health problem globally. This narrative overview examines clinical management strategies for IgE-mediated food allergy in children around the world to understand variations in practice. Information was drawn from clinical practice guidelines, recent research, the websites of professional and governmental bodies with expertise in food allergy, and clinical experts from a broad cross-section of geographical regions. The structure and delivery of clinical services, allergen avoidance and food labeling, and resources to support the management of allergic reactions in the community are discussed in detail. The adoption of emerging food immunotherapies is also explored. Wide variations in clinical management of food allergy were apparent across the different countries. Common themes were continuing issues with access to specialist care and recognition of the need to balance risk reduction with dietary and social restrictions to avoid unnecessary detrimental impacts on the quality of life of food allergy sufferers. Findings highlight the need for standardized presentation of practice and priorities, and may assist clinicians and researchers when engaging with government and funding agencies to address gaps.
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Affiliation(s)
- Melanie Lloyd
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
| | - Paxton Loke
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, Monash University, Clayton, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Scott H Sicherer
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael R Perkin
- Population Health Research Institute, St. George's, University of London, London, United Kingdom
| | - Robert Boyle
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Agnes Sze Yin Leung
- Department of Paediatrics, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong; Hong Kong Hub of Paediatric Excellence, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Bee Wah Lee
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Michael Levin
- Division of Paediatric Allergology, University of Cape Town, Cape Town, South Africa
| | - Katharina Blumchen
- Department of Children and Adolescent Medicine, Division of Pneumology, Allergology and Cystic Fibrosis, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Alessandro Fiocchi
- Translational Research in Paediatric Specialities Area, Allergy Division, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Sagamihara, Japan
| | - Lucila Camargo Lopes de Oliveira
- Department of Paediatrics, Division of Allergy, Clinical Immunology and Rheumatology, Federal University of São Paulo, São Paulo, Brazil
| | - Mimi L K Tang
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Parkville, VIC, Australia.
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Stiles SL, Roche I, Said M, Clifford RM, Sanfilippo FM, Loh R, Salter SM. Overview of registries for anaphylaxis: a scoping review. JBI Evid Synth 2022; 20:2656-2696. [PMID: 35942638 DOI: 10.11124/jbies-21-00182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE This review aimed to describe the scope and operational features of anaphylaxis registries, and to assess their contribution to improving knowledge of anaphylaxis and care of patients who experience anaphylaxis by measuring their research output. INTRODUCTION Structured data collection and reporting systems, such as registries, are needed to better understand the burden of anaphylaxis and to protect the growing number of patients with severe allergy. There is a need to characterize current anaphylaxis registries to identify their value in anaphylaxis surveillance, management, and research. Information synthesized in this review will provide knowledge on benefits and gaps in current registries, which may inform the implementation and global standardization of future anaphylaxis reporting systems. INCLUSION CRITERIA This scoping review considered literature describing registries worldwide that enroll patients who have experienced anaphylaxis. Published and gray literature sources were included if they described the scope and operational features of anaphylaxis registries. METHODS This review followed the JBI methodology for scoping reviews. Embase, MEDLINE, Scopus, and CINAHL were searched for relevant articles. Identified keywords and index terms were adapted for searches of gray literature sources, using Google advanced search functions. Only full-text studies in English were considered for inclusion. Two independent reviewers conducted title and abstract screening and those that did not meet the inclusion criteria were excluded. The full text of potentially relevant articles were retrieved; full-text screening and data extraction were also conducted by two independent reviewers. Any discrepancies were resolved through discussion or with a third reviewer. Tables and a narrative summary were used to describe and compare the scope and features (eg, inclusion criteria, patient demographics, clinical symptoms) of the identified anaphylaxis registries, and to outline their output to assess their contribution to research and clinical practice for anaphylaxis. RESULTS A total of 77 full-text publications and eight gray literature sources were used to extract data. The literature search identified 19 anaphylaxis registries, with sites in 28 countries including Europe, the United Kingdom, Canada, the United States, Korea, and Australia. The main purposes of the identified registries were to collect clinical data for research; provide clinical support tools to improve patient care; and operate as allergen surveillance systems to protect the wider community with allergies. Differences in inclusion and health care settings exist, with 11 collecting data on anaphylaxis of any cause, two on food reactions alone, three on fatal anaphylaxis, one on perioperative anaphylaxis, and two on allergic reactions (including anaphylaxis). Five registries enroll cases in allergy centers, five in hospital settings, one in schools, and others target a combination of general practitioners, specialists in emergency departments, and other relevant hospital departments and allergy outpatient clinics. Only three registries operate under a mandatory framework. A total of 57 publications were considered research outputs from registries. All registries except two have published studies from collected data, with the greatest number of articles published from 2019 to the present. Publications mostly addressed questions regarding demographic profile, causes and cofactors, severity, fatal reactions, and gaps in management. CONCLUSIONS This review demonstrated that anaphylaxis registries differ in their scope and operation, having been established for different purposes. Importantly, registries have contributed significantly to research, which has highlighted gaps in anaphylaxis management, provoking allergens, and informed targets for prevention for severe and fatal events. Beyond this, registries relay information about anaphylaxis to clinicians and regulatory bodies to improve patient care and protect the community. The ability to link registry data with other health datasets, standardization of data across registries, and incorporation of clinical care indicators to promote quality health care across the health system represent important targets for future systems.
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Affiliation(s)
| | | | - Maria Said
- The University of Western Australia, Perth, WA, Australia.,Allergy and Anaphylaxis Australia, Sydney, NSW, Australia.,National Allergy Strategy, Sydney, NSW, Australia
| | | | | | - Richard Loh
- The University of Western Australia, Perth, WA, Australia.,Perth Children's Hospital, Perth, WA, Australia.,Australasian Society of Clinical Immunology and Allergy (ASCIA), Sydney, NSW, Australia
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Alqurashi W, Shaker M, Wells GA, Collins GS, Greenhawt M, Curran JA, Zemek R, Schuh S, Ellis A, Gerdts J, Kreviazuk C, Dixon A, Eltorki M, Freedman SB, Gravel J, Poonai N, Worm M, Plint AC. Canadian Anaphylaxis Network-Predicting Recurrence after Emergency Presentation for Allergic REaction (CAN-PREPARE): a prospective, cohort study protocol. BMJ Open 2022; 12:e061976. [PMID: 36316072 PMCID: PMC9628530 DOI: 10.1136/bmjopen-2022-061976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Anaphylaxis is a severe, potentially fatal multiorgan system manifestation of an allergic reaction. The highest incidence of anaphylaxis is in children and adolescents. Biphasic anaphylaxis (BA) is defined as the recurrence of allergic symptoms after resolution of an initial reaction. It has been reported to occur in 10%-20% of cases within 1-48 hours from the onset of the initial reaction. The dilemma for physicians is determining which patients with resolved anaphylaxis should be observed for BA and for how long. Guidelines for duration of postanaphylaxis monitoring vary, are based on limited evidence and can have unintended negative impacts on patient safety, quality of life and healthcare resources. The objectives of this study are to derive a prognostic model for BA and to develop a risk-scoring system that informs disposition decisions of children who present to emergency departments (ED) with anaphylaxis. METHODS AND ANALYSIS This prospective multicentre cohort study will enrol 1682 patients from seven paediatric EDs that are members of the Paediatric Emergency Research Canada network. We will enrol patients younger than 18 years of age with an allergic reaction meeting anaphylaxis diagnostic criteria. Trained ED research assistants will screen, obtain consent and prospectively collect study data. Research assistants will follow patients during their ED visit and ascertain, in conjunction with the medical team, if the patient develops BA. A standardised follow-up survey conducted following study enrolment will determine if a biphasic reaction occurred after ED disposition. Model development will conform to the broad principles of the PROGRESS (Prognosis Research Strategy) framework and reporting will follow the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis Statement. ETHICS AND DISSEMINATION Ethics approval has been received from all participating centres. Our dissemination plan focuses on informing clinicians, policy makers and parents of the results through publication in peer-reviewed journals and broadcasting on multiple media platforms. TRIAL REGISTRATION NUMBER NCT05135377.
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Affiliation(s)
- Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Marcus Shaker
- Section of Allergy and Clinical Immunology, Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire, USA
| | - George A Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Gary Stephen Collins
- Centre for Statistics in Medicine, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Janet A Curran
- Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Roger Zemek
- Department of Pediatrics and Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Suzanne Schuh
- Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anne Ellis
- Division of Allergy and Immunology, Queen's University, Kingston, Ontario, Canada
| | | | - Cheryl Kreviazuk
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Andrew Dixon
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Stephen B Freedman
- Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Jocelyn Gravel
- Centre Hospitalier Universitaire Sainte-Justine, Universite de Montreal, Montreal, Québec, Canada
| | - Naveen Poonai
- Departments of Paediatrics, Internal Medicine, Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology and Allergy, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Amy C Plint
- Department of Pediatrics and Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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Anaphylaxis in Children and Adolescents: Greek Data Analysis from the European Anaphylaxis Registry (NORA). J Pers Med 2022; 12:jpm12101614. [PMID: 36294753 PMCID: PMC9604916 DOI: 10.3390/jpm12101614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/09/2022] [Accepted: 09/26/2022] [Indexed: 11/07/2022] Open
Abstract
The European Anaphylaxis Registry (NORA) was designed in order to create a comprehensive Anaphylaxis Registry regarding anaphylactic reactions characteristics and management in several European countries, including Greece. This study aims to analyze Greek data obtained in the NORA framework and describe anaphylaxis’ characteristics in this pediatric cohort. An online questionnaire was filled out by the Allergy Unit of the 2nd Pediatric Department of NKUA, regarding reported anaphylaxis characteristics. A total of 284 pediatric patients were analyzed. Patients were predominantly male. A previous, mild reaction (59.5%) to the same allergen was documented in 44.4% of patients. The most common system involved was skin and/or mucosa, followed by the respiratory system. Food was the most common eliciting factor (82.4%). First line treatment was most administered solely by a healthcare professional, followed by a lay person (38.7%). Auto injected adrenaline use by lay persons was third in frequency (29.2%). Most patients received post-reaction counseling and appropriate drug prescription. This study provides insight in anaphylactic cases’ characteristics and management in a Greek pediatric cohort. A low rate of adrenaline autoinjector administration was noted in lay people; however, drug prescription and counseling following the reaction could help increase correct acute anaphylaxis management in the future.
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8
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Tanverdi MS, Wiersma A, Kim KM, Hicks AG, Mistry RD. Anaphylaxis in Children. Pediatr Emerg Care 2022; 38:456-461. [PMID: 36040466 DOI: 10.1097/pec.0000000000002812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Anaphylaxis is a potentially life-threatening event in children, commonly encountered in the prehospital and emergency department settings. Recently published clinical guidelines emphasize early recognition of anaphylaxis and administration of epinephrine as the mainstay of management. Literature regarding adjuvant therapies, biphasic reactions, observation times, and disposition of patients with anaphylaxis remains controversial. In this article, we will review the background and pathophysiology of anaphylaxis, as well as the diagnostic approach, management, and future directions of anaphylaxis in children.
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Affiliation(s)
- Melisa S Tanverdi
- From the Assistant Professors, Department of Pediatrics, Section of Pediatric Emergency Medicine (Tanverdi, Wiersma, Kim)
| | - Alexandria Wiersma
- From the Assistant Professors, Department of Pediatrics, Section of Pediatric Emergency Medicine (Tanverdi, Wiersma, Kim)
| | - Kristin M Kim
- From the Assistant Professors, Department of Pediatrics, Section of Pediatric Emergency Medicine (Tanverdi, Wiersma, Kim)
| | - Allison G Hicks
- Assistant Professor, Department of Pediatrics, Section of Allergy and Immunology (Hicks)
| | - Rakesh D Mistry
- Professor, Department of Pediatrics, Section of Pediatric Emergency Medicine (Mistry), Children's Hospital Colorado, University of Colorado School of Medicine Aurora, CO
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Jiang N, Xu W, Huang H, Hou X, Xiang L. Anaphylaxis in Chinese Children with Pollen Sensitization: Triggers, Clinical Presentation, and Acute Management. J Asthma Allergy 2022; 15:633-643. [PMID: 35603012 PMCID: PMC9122664 DOI: 10.2147/jaa.s363113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/05/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Pollen sensitization is increasing in children. However, there is little evidence regarding the characteristics of anaphylaxis in individuals with pollen sensitization. Patients and Methods We conducted a retrospective study of patients with anaphylaxis combined with pollen sensitization who attended an allergy department in a tertiary children’s hospital from 2014 to 2021. Results A total of 157 anaphylaxis events in 108 patients were analyzed; the mean age at the reaction was 5.8 ± 4.17 years. A total of 99.1% (107/108) of the patients came from northern China. The most common sensitizing pollen was mugwort (93.5%,101/108), followed by ragweed (68.5%, 74/108) and birch (40.7%, 44/108). A total of 76.9% (83/108) of the patients showed polysensitization to pollen. Allergic rhinitis/conjunctivitis was the most common comorbidity (87.0%, 94/108). Children with severe anaphylaxis were more likely to have a history of recurrent urticaria (16.1% vs 3.9%, p = 0.028). The most frequently implicated foods were fruits/vegetables (22.3%, 35/157), followed by wheat (8.9%, 14/157) and milk (8.3%, 13/157), and the most common fruit allergen was peach (n = 7). Of 14% (22/157) exercise-induced reactions, 63.6% (14/22) occurred in pollen season. Skin symptoms were the most frequent (86.0%, 135/157) symptoms, followed by respiratory (73.9%, 116/157) and gastrointestinal (21%, 33/157) symptoms. Regarding acute management, only 7.4% of the patients were treated with epinephrine. Conclusion Our findings revealed the characteristics of anaphylaxis in children with pollen sensitization. Fruits/vegetables accounted for a substantial percentage of anaphylaxis triggers. The suboptimal use of epinephrine highlights the need for educational programs promoting the use of epinephrine.
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Affiliation(s)
- Nannan Jiang
- Department of Allergy, Beijing Children′s Hospital, Capital Medical University, National Center for Children′s Health; Key Laboratory of Major Diseases in Children, Ministry of Education; National Clinical Research Center for Respiratory Diseases, Beijing, People’s Republic of China
| | - Wei Xu
- Department of Allergy, Beijing Children′s Hospital, Capital Medical University, National Center for Children′s Health; Key Laboratory of Major Diseases in Children, Ministry of Education; National Clinical Research Center for Respiratory Diseases, Beijing, People’s Republic of China
| | - Huijie Huang
- Department of Allergy, Beijing Children′s Hospital, Capital Medical University, National Center for Children′s Health; Key Laboratory of Major Diseases in Children, Ministry of Education; National Clinical Research Center for Respiratory Diseases, Beijing, People’s Republic of China
| | - Xiaoling Hou
- Department of Allergy, Beijing Children′s Hospital, Capital Medical University, National Center for Children′s Health; Key Laboratory of Major Diseases in Children, Ministry of Education; National Clinical Research Center for Respiratory Diseases, Beijing, People’s Republic of China
| | - Li Xiang
- Department of Allergy, Beijing Children′s Hospital, Capital Medical University, National Center for Children′s Health; Key Laboratory of Major Diseases in Children, Ministry of Education; National Clinical Research Center for Respiratory Diseases, Beijing, People’s Republic of China
- Correspondence: Li Xiang, Department of Allergy, Beijing Children’s Hospital, Capital Medical University, National Center for Children′s Health, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, People’s Republic of China, Tel +861059616934, Fax +861059616934, Email
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10
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Jiang N, Xu W, Xiang L. Age-related differences in characteristics of anaphylaxis in Chinese children from infancy to adolescence. World Allergy Organ J 2021; 14:100605. [PMID: 34868452 PMCID: PMC8605427 DOI: 10.1016/j.waojou.2021.100605] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/13/2021] [Accepted: 10/21/2021] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Little is known about anaphylaxis in Chinese children. This study aimed to determine the age-specific patterns of anaphylaxis in Chinese children. METHODS We conducted a retrospective study of anaphylaxis cases attending an allergy department in a tertiary children's hospital. RESULTS A total of 279 anaphylactic reactions in 177 patients were analyzed. Overall, 57.6% (102/177) of first anaphylaxis events occurred in infants (0-2 ys). Foods were the most common culprits (88.5%), followed by food + exercise/exercise (4.7%), and drugs (4.3%). The main food allergens were cow's milk (32.9%), egg (21.4%), and wheat (20.7%) in infants, compared with fruits/vegetables at 35.9% in preschool-age children (3-6 ys) and 31.6% in school-age children (7-12 ys). The most commonly implicated drug triggers were vaccines (n = 5, comprising DTaP n = 2, group A + C meningococcal polysaccharide vaccine n = 1, Sabin vaccine n = 1, and not specified n = 1). Among the 5 vaccine-induced anaphylaxis patients, 4 had severe cow's milk allergy. The clinical manifestations were mainly mucocutaneous (86.0%), followed by respiratory (68.8%), gastrointestinal (23.7%), neurological (10.4%), and cardiovascular (0.7%). Compared with patients of other ages, infants had higher rates of hives (0-2ys 77.4%, 3-6ys 50%,7-12ys 57.9%, 13-17ys 38.9%, p = 0.016) and vomiting (0-2ys 20.7%, 3-6ys 1.6%,7-12ys 8.8%, p < 0.001), while wheezing was more frequent in school-age children (0-2ys 21.4%, 3-6ys 25%, 7-12ys 38.6%, 13-17ys 5.6%, p = 0.017) and abdominal pain was more common in adolescents (0-2ys 2.1%,3-6ys 15.6%, 7-12ys 14.0%, 13-17ys 72.3%, p < 0.001). Regarding treatment, 9.3% of anaphylaxis events and 24.1% of life-threatening reactions were treated with epinephrine. CONCLUSIONS We observed age-related clinical patterns of anaphylaxis in this study, with hives and vomiting most commonly reported in infants and cardiovascular symptoms rarely reported in children. Wheat was the third most culprit food allergen after egg and milk in infancy. Education regarding more aggressive use of epinephrine in the emergency setting is clearly needed. Recognition of age-related symptoms in anaphylaxis can aid physicians in prompt diagnosis and acute management.
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Affiliation(s)
- Nannan Jiang
- Department of Allergy, Beijing Children′s Hospital, Capital Medical University, National Center for Children′s Health, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
- China National Clinical Research Center for Respiratory Diseases, China
| | - Wei Xu
- Department of Allergy, Beijing Children′s Hospital, Capital Medical University, National Center for Children′s Health, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
- China National Clinical Research Center for Respiratory Diseases, China
| | - Li Xiang
- Department of Allergy, Beijing Children's Hospital, Capital Medical University, No.56 Nanlishi Road, Xicheng District, Beijing, 100045, China
- China National Clinical Research Center for Respiratory Diseases, China
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Taylor SL, Marsh JT, Koppelman SJ, Kabourek JL, Johnson PE, Baumert JL. A perspective on pea allergy and pea allergens. Trends Food Sci Technol 2021. [DOI: 10.1016/j.tifs.2021.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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12
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Gaspar Â, Santos N, Faria E, Pereira AM, Gomes E, Câmara R, Rodrigues-Alves R, Borrego LM, Carrapatoso I, Carneiro-Leão L, Morais-Almeida M, Delgado L, Pedro E, Branco-Ferreira M. Anaphylaxis in children and adolescents: The Portuguese Anaphylaxis Registry. Pediatr Allergy Immunol 2021; 32:1278-1286. [PMID: 33774834 DOI: 10.1111/pai.13511] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 03/07/2021] [Accepted: 03/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anaphylaxis is increasing at pediatric age; however, its characterization is hampered by underdiagnosis and underreporting. The aim of this study was to identify the causes of anaphylaxis in children and adolescents in Portugal, thus contributing to a better knowledge of its etiology, clinical manifestations, and management. METHODS During a 10-year period, a nationwide notification system for anaphylaxis was implemented, with voluntary reporting by allergists. Data on 533 patients under 18 years of age with anaphylaxis were included. RESULTS Mean age was 8.5 ± 4.9 years, 61% were male; 45% had asthma. Mean age at the first anaphylaxis episode was 5.3 ± 4.7 years (ranging from 1 month to 17 years of age), 63% at pre-school age. Most reactions occurred at home (57%). Food-induced anaphylaxis was the leading cause (77%). The main culprit foods were cow's milk (32%), tree nuts (16%), shellfish (13%), egg (12%), fresh fruits (11%), fish (8%), and peanut (8%). Other causes included drugs (11%), insect sting (5%), cold-induced anaphylaxis (4%), exercise-induced anaphylaxis (2%), latex (1%), and idiopathic anaphylaxis (1%). Most patients (83%) were admitted to the emergency department; only 46% received adrenaline treatment. Recurrence of anaphylaxis occurred in 41% of the patients (3 or more episodes in 21%). An adrenaline autoinjector was used in 9% of the patients. CONCLUSIONS In the Portuguese pediatric population, food is the leading cause of anaphylaxis. Undertreatment with adrenaline and high recurrence of anaphylaxis highlight the need to improve both the diagnosis and the therapeutic management of this life-threatening entity.
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Affiliation(s)
- Ângela Gaspar
- Immunoallergy Department, Hospital da Luz Lisboa, Lisbon, Portugal
| | - Natacha Santos
- Immunoallergy Department, Centro Hospitalar Universitário Algarve, Portimão, Portugal
| | - Emília Faria
- Immunoallergy Department, Centro Hospitalar Universitário Coimbra, Coimbra, Portugal
| | | | - Eva Gomes
- Immunoallergy Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Rita Câmara
- Immunoallergology Unit, Hospital Dr. Nélio Mendonça, Funchal, Portugal
| | | | - Luís-Miguel Borrego
- Immunoallergy Department, Hospital da Luz Lisboa, Lisbon, Portugal.,CEDOC, Comprehensive Health Research Center (CHRC), NOVA Medical School, Nova University of Lisbon, Lisbon, Portugal
| | - Isabel Carrapatoso
- Immunoallergy Department, Centro Hospitalar Universitário Coimbra, Coimbra, Portugal
| | | | | | - Luís Delgado
- Immunoallergology Unit, Hospital CUF Porto and Instituto CUF Porto, Porto, Portugal.,Immunoallergy Department, Centro Hospitalar São João, Porto, Portugal.,Basic and Clinical Immunology Unit, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Elisa Pedro
- Immunoallergy Department, Centro Hospitalar Lisboa Norte, Hospital Santa Maria, Lisbon, Portugal
| | - Manuel Branco-Ferreira
- Immunoallergy Department, Centro Hospitalar Lisboa Norte, Hospital Santa Maria, Lisbon, Portugal.,Immunoallergology University Clinic, Faculty of Medicine of the University of Lisbon, Lisbon, Portugal
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Shin M. Food allergies and food-induced anaphylaxis: role of cofactors. Clin Exp Pediatr 2021; 64:393-399. [PMID: 33181008 PMCID: PMC8342881 DOI: 10.3345/cep.2020.01088] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/08/2020] [Indexed: 11/29/2022] Open
Abstract
Food allergies and food-induced anaphylaxis are important health problems. Several cofactors modulating the onset of anaphylaxis have been identified. In the presence of cofactors, allergic reactions may be induced at lower doses of food allergens and/or become severe. Exercise and concomitant infections are well-documented cofactors of anaphylaxis in children. Other factors such as consumption of nonsteroidal anti-inflammatory drugs, alcohol ingestion, and stress have been reported. Cofactors reportedly play a role in approximately 30% of anaphylactic reactions in adults and 14%-18.3% in children. Food-dependent exercise-induced anaphylaxis (FDEIA) is the best-studied model of cofactor-induced anaphylaxis. Wheat-dependent exercise-induced anaphylaxis, the most common FDEIA condition, has been studied the most. The mechanisms of action of cofactors have not yet been fully identified. This review aims to educate clinicians on recent developments in the role of cofactors and highlight the importance of recognizing cofactors in food allergies and food-induced anaphylaxis.
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Affiliation(s)
- Meeyong Shin
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, Bucheon, Korea
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14
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Maris I, Dölle‐Bierke S, Renaudin J, Lange L, Koehli A, Spindler T, Hourihane J, Scherer K, Nemat K, Kemen C, Neustädter I, Vogelberg C, Reese T, Yildiz I, Szepfalusi Z, Ott H, Straube H, Papadopoulos NG, Hämmerling S, Staden U, Polz M, Mustakov T, Cichocka‐Jarosz E, Cocco R, Fiocchi AG, Fernandez‐Rivas M, Worm M, Grünhagen J, Wittenberg M, Beyer K, Henschel A, Küper S, Möser A, Fuchs T, Ruëff F, Wedi B, Hansen G, Buck T, Büsselberg J, Drägerdt R, Pfeffer L, Dickel H, Körner‐Rettberg C, Merk H, Lehmann S, Bauer A, Nordwig A, Zeil S, Hannapp C, Wagner N, Rietschel E, Hunzelmann N, Huseynow I, Treudler R, Aurich S, Prenzel F, Klimek L, Pfaar O, Reider N, Aberer W, Varga E, Bogatu B, Schmid‐Grendelmeier P, Guggenheim R, Riffelmann F, Kreft B, Kinaciyan K, Hartl L, Ebner C, Horak F, Brehler R, Witte J, Buss M, Hompes S, Bieber T, Gernert S, Bücheler M, Rabe U, Brosi W, Nestoris S, Hawranek T, Lang R, Bruns R, Pföhler C, Eng P, Schweitzer‐Krantz S, Meller S, Rebmann H, Fischer J, Stichtenoth G, Thies S, Gerstlauer M, Utz P, Neustädter I, Klinge J, Volkmuth S, Plank‐Habibi S, Schilling B, Kleinheinz A, Brückner A, Schäkel K, Manolaraki I, Kowalski M, Solarewicz‐Madajek K, Tscheiller S, Seidenberg J, Cardona V, Garcia B, Bilo M, Cabañes Higuero N, Vega Castro A, Poziomkowska‐Gęsicka I, Büsing S, Virchow C, Christoff G, Jappe U, Müller S, Knöpfel F, Correard A, Rogala B, Montoro A, Brandes A, Muraro A, Zimmermann N, Hernandez D, Minale P, Niederwimmer J, Zahel B, Dahdah L, Arasi S, Reissig A, Eitelberger F, Asero R, Hermann F, Zeidler S, Pistauer S, Geißler M, Ensina L, Plaza Martin A, Meister J, Stieglitz S, Hamelmann E. Peanut-induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry. Allergy 2021; 76:1517-1527. [PMID: 33274436 DOI: 10.1111/all.14683] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/26/2020] [Accepted: 11/10/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents. METHODS Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre. RESULTS 3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004). CONCLUSIONS The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.
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Affiliation(s)
- Ioana Maris
- Bon Secours Hospital Cork/Paediatrics and Child HealthUniversity College Cork Cork Ireland
| | - Sabine Dölle‐Bierke
- Division of Allergy and Immunology Department of Dermatology, Venereology and Allergology Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | | | - Lars Lange
- Department of Paediatrics St. Marien‐Hospital Bonn Germany
| | - Alice Koehli
- Division of Allergology University Children’s Hospital Zurich Zürich Switzerland
| | - Thomas Spindler
- Department of Paediatrics Medical Campus Hochgebirgsklinik Davos Davos Switzerland
| | - Jonathan Hourihane
- Paediatrics and Child Health Royal College of Surgeons in Ireland Dublin Ireland
- Children’s Health Ireland Dublin Ireland
| | | | - Katja Nemat
- Practice for paediatric pneumology and allergology Kinderzentrum Dresden‐Friedrichstadt Dresden Germany
| | - C. Kemen
- Department of Paediatrics Children’s Hospital WILHELMSTIFT Hamburg Germany
| | - Irena Neustädter
- Department of Paediatrics Hallerwiese Cnopfsche Kinderklinik Nuremberg Germany
| | - Christian Vogelberg
- Department of Paediatrics Universitätsklinikum Carl Gustav CarusTechnical University Dresden Germany
| | - Thomas Reese
- Department of Paediatrics Mathias‐Spital Rheine Rheine Germany
| | - Ismail Yildiz
- Department of Paediatrics Friedrich‐Ebert‐Krankenhaus Neumuenster Germany
| | - Zsolt Szepfalusi
- Division of Paediatric Pulmonology, Allergology and Endocrinology Department of Paediatrics and Adolescent Medicine Competence Center Paediatrics Medical University of Vienna Vienna Austria
| | - Hagen Ott
- Division of Paediatric Dermatology and Allergology Epidermolysis bullosa‐Centre HannoverChildren’s Hospital AUF DER BULT Hanover Germany
| | - Helen Straube
- Division of Allergology Darmstädter Kinderkliniken Prinzessin Margaret Darmstadt Germany
| | - Nikolaos G. Papadopoulos
- Allergy Department 2nd Paediatric Clinic National and Kapodistrian University of Athens Athens Greece
- Division of Infection Immunity& Respiratory Medicine University of Manchester Manchester UK
| | - Susanne Hämmerling
- Division of Paediatric Pulmonology and Allergology University Children`s Hospital Heidelberg Heidelberg Germany
| | - Ute Staden
- Paediatric Pneumology & Allergology Medical practice Klettke/Staden Berlin Germany
| | - Michael Polz
- Department of Paediatrics GPR Klinikum Rüsselsheim Germany
| | - Tihomir Mustakov
- Chair of Allergy University Hospital Alexandrovska Sofia Bulgaria
| | - Ewa Cichocka‐Jarosz
- Department of Paediatrics Jagiellonian University Medical College Krakow Poland
| | - Renata Cocco
- Division of Allergy Clinical Immunology and Rheumatology Department of Paediatrics Federal University of São Paulo São Paulo Brazil
| | | | | | - Margitta Worm
- Division of Allergy and Immunology Department of Dermatology, Venereology and Allergology Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
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15
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Blank S, Grosch J, Ollert M, Bilò MB. Precision Medicine in Hymenoptera Venom Allergy: Diagnostics, Biomarkers, and Therapy of Different Endotypes and Phenotypes. Front Immunol 2020; 11:579409. [PMID: 33193378 PMCID: PMC7643016 DOI: 10.3389/fimmu.2020.579409] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022] Open
Abstract
Allergic reactions to stings of Hymenoptera species may be severe and are potentially fatal deviations of the immunological response observed in healthy individuals. However, venom-specific immunotherapy (VIT) is an immunomodulatory approach able to cure venom allergy in the majority of affected patients. An appropriate therapeutic intervention and the efficacy of VIT not only depend on a conclusive diagnosis, but might also be influenced by the patient-specific manifestation of the disease. As with other diseases, it should be borne in mind that there are different endotypes and phenotypes of venom allergy, each of which require a patient-tailored disease management and treatment scheme. Reviewed here are different endotypes of sting reactions such as IgE-mediated allergy, asymptomatic sensitization or a simultaneous presence of venom allergy and mast cell disorders including particular considerations for diagnosis and therapy. Additionally, phenotypical manifestations of venom allergy, as e.g. differences in age of onset and disease severity, multiple sensitization or patients unsusceptible to therapy, are described. Moreover, biomarkers and diagnostic strategies that might reflect the immunological status of the patient and their value for therapeutic guidance are discussed. Taken together, the increasing knowledge of different disease manifestations in venom hypersensitivity and the growing availability of diagnostic tools open new options for the classification of venom allergy and, hence, for personalized medical approaches and precision medicine in Hymenoptera venom allergy.
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Affiliation(s)
- Simon Blank
- Center of Allergy and Environment (ZAUM), Technical University of Munich, School of Medicine and Helmholtz Center Munich, German Research Center for Environmental Health, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Johannes Grosch
- Center of Allergy and Environment (ZAUM), Technical University of Munich, School of Medicine and Helmholtz Center Munich, German Research Center for Environmental Health, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Markus Ollert
- Department of Infection and Immunity, Luxembourg Institute of Health (LIH), Esch-sur-Alzette, Luxembourg.,Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis, University of Southern Denmark, Odense, Denmark
| | - Maria Beatrice Bilò
- Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy.,Allergy Unit, Department of Internal Medicine, University Hospital of Ancona, Ancona, Italy
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17
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Carter MC, Akin C, Castells MC, Scott EP, Lieberman P. Idiopathic anaphylaxis yardstick: Practical recommendations for clinical practice. Ann Allergy Asthma Immunol 2019; 124:16-27. [PMID: 31513910 DOI: 10.1016/j.anai.2019.08.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/20/2019] [Accepted: 08/27/2019] [Indexed: 12/18/2022]
Abstract
Anaphylaxis is considered idiopathic when there is no known trigger. The signs and symptoms of idiopathic anaphylaxis (IA) are identical to those of anaphylaxis because of a known cause and can include cutaneous, circulatory, respiratory, gastrointestinal, and neurologic symptoms. Idiopathic anaphylaxis can be a frustrating disease for patients and health care providers. Episodes are unpredictable, and differential diagnosis is challenging. Current anaphylaxis guidelines have little specific guidance regarding differential diagnosis and long-term management of IA. Therefore, the objective of the Idiopathic Anaphylaxis Yardstick is to use published data and the authors' combined clinical experience to provide practical recommendations for the diagnosis and management of patients with IA.
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Affiliation(s)
| | - Cem Akin
- Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Mariana C Castells
- Department of Medicine, Division of Rheumatology, Immunology, and Allergy, Mastocytosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Phil Lieberman
- Departments of Medicine and Pediatrics, Divisions of Allergy and Immunology, University of Tennessee, Memphis, Tennessee.
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Cardinale F, Amato D, Mastrototaro MF, Caffarelli C, Crisafulli G, Franceschini F, Liotti L, Caimmi S, Bottau P, Saretta F, Mori F, Bernardini R. Drug-induced anaphylaxis in children. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:30-35. [PMID: 30830059 PMCID: PMC6502178 DOI: 10.23750/abm.v90i3-s.8172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/01/2019] [Indexed: 12/03/2022]
Abstract
Anaphylaxis represents one of the most frequent medical emergencies in childhood. However, as compared to adults, drugs are less common triggers of anaphylaxis in children, with a frequency which is increasing from infancy to adolescence. Deaths seldom occur, maybe because of the paucity of comorbidities in children. Antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs) are the main elicitors in drug-induced anaphylaxis in children. Both immune-mediated (mainly IgE-mediated) and non immune-mediated may be involved. IgG-mediated and complement-mediated mechanisms has been also hypothesized. Correct management relies on a right diagnosis and prompt therapy. A proper work-up is also important to prevent further potentially fatal re-exposures to the same drug or other structurally similar molecules but also unnecessary avoidance of medications not representing the culprit of the episode.
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Affiliation(s)
- Fabio Cardinale
- UOC di Pediatria, Servizio di Allergologia e Pneumologia Pediatrica, Azienda Ospedaliera-Universitaria "Consorziale-Policlinico", Ospedale Pediatrico Giovanni XXIII, Bari, Italy.
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19
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Versluis A, van Os-Medendorp H, Blom WM, Michelsen-Huisman AD, Castenmiller JJM, Noteborn HPJM, Houben GF, Knulst AC. Potential cofactors in accidental food allergic reactions are frequently present but may not influence severity and occurrence. Clin Exp Allergy 2018; 49:207-215. [PMID: 30244525 DOI: 10.1111/cea.13282] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 09/06/2018] [Accepted: 09/19/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cofactors, such as physical exercise and alcohol intake, might be associated with the severity or occurrence of food allergic reactions. OBJECTIVE To gain insight into the frequency of presence of potential cofactors in accidental food allergic reactions in adults and to what extent these factors influence the severity and occurrence of allergic reactions. METHODS A prospective cohort study was conducted, with a 1-year follow-up in adult patients with a physician-diagnosed food allergy. Patients were required to fill in a questionnaire after every accidental allergic reactions to food over a 1-year period. The primary outcome measure was the frequency that potential cofactors were present in these allergic reactions. RESULTS A total of 157 patients were included, of which 46% reported a total of 153 reactions during a 1-year follow-up period. In 74% of the reactions, ≥1 potential cofactor was reported to be present: tiredness (38%), alcohol intake (16%), stress (14%), symptoms of pollinosis (16%), symptoms of asthma (9%), sickness/flu (3%), physical exercise (3%) and use of analgesics (2%). More than one potential cofactor was reported in almost half of all reactions (47%). There was no significant difference in the presence of these factors between mild, moderate and severe reactions (P = 0.522). In the total study population, 9% of the patients used medication that might act as cofactor (antacids, angiotensin receptor blockers [ARBs], beta blockers and angiotensin-converting enzyme inhibitors [ACEIs]) on a daily basis, which however did not influence the occurrence of reactions. Furthermore, 38% daily used allergy-suppressing medication. CONCLUSIONS Although factors suggested to be cofactors were frequently present during accidental food allergic reactions, we found no evidence for an association between the potential cofactors examined and reaction severity, in a population where most reactions were of mild to moderate severity.
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Affiliation(s)
- Astrid Versluis
- Department of Dermatology/Allergology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - W Marty Blom
- TNO, Netherlands Organization for Applied Scientific Research, Zeist, The Netherlands
| | | | | | | | - Geert F Houben
- TNO, Netherlands Organization for Applied Scientific Research, Zeist, The Netherlands
| | - André C Knulst
- Department of Dermatology/Allergology, University Medical Center Utrecht, Utrecht, The Netherlands
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20
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Eller E, Muraro A, Dahl R, Mortz CG, Bindslev-Jensen C. Assessing severity of anaphylaxis: a data-driven comparison of 23 instruments. Clin Transl Allergy 2018; 8:29. [PMID: 30079223 PMCID: PMC6069559 DOI: 10.1186/s13601-018-0215-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 07/02/2018] [Indexed: 12/25/2022] Open
Abstract
Backgroud The severity of an allergic reaction can range from mild local symptoms to anaphylactic shock. To score this, a number of instruments have been developed, although heterogeneous in design and purpose. Severity scoring algorithms are therefore difficult to compare, but are frequently used beyond their initial purpose. Our objective was to compare the most used severity scoring instruments by a data-driven approach on both milder reactions and anaphylaxis. Methods All positive challenges to foods or drugs (n = 2828) including anaphylaxis (n = 616) at Odense University Hospital, Denmark from 1998 to 2016 were included and severity was scored according to Sampson5. Based on recommendations from an expert group, the symptoms and values from Sampson5 were for all reactions and anaphylaxis only translated and compared by kappa statistics with 22 instruments, ranging from 3 to 6 steps. Results For milder reactions, there was a significant correlation between the number of steps in an instrument and the number of challenges that could be translated, whereas all instruments were good to identify food anaphylaxis. Some instruments scored reactions more severely than Sampson5, other scored them milder and some scored food and drug challenges differently. Instruments for hymenoptera reactions were difficult to apply on food and drug reactions, and thus distributed severity differently. Algorithms hampered the translation between instruments, and 7 instruments were poor concerning drug anaphylaxis, including the only instrument developed specifically for drug reactions. Conclusion The distributions of severity differed between the 23 instruments in both food and drug allergy, and thus rendering translation especially between scoring systems with 3 and 5 grades difficult. Fine-graded and simple instruments are preferred for comparison especially among milder reactions, and instruments applied to non-intended situations may not reflect a true severity picture.
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Affiliation(s)
- Esben Eller
- 1Odense Research Center for Anaphylaxis (ORCA), Department of Dermatology and Allergy Center, Odense University Hospital, Odense, Denmark
| | - Antonella Muraro
- 2Food Allergy Referral Centre - Veneto Region, Department of Women and Child Health, Padua University Hospital, Padua, Italy
| | - Ronald Dahl
- 1Odense Research Center for Anaphylaxis (ORCA), Department of Dermatology and Allergy Center, Odense University Hospital, Odense, Denmark.,3GSK, Brentford, Middlesex, UK
| | - Charlotte Gotthard Mortz
- 1Odense Research Center for Anaphylaxis (ORCA), Department of Dermatology and Allergy Center, Odense University Hospital, Odense, Denmark
| | - Carsten Bindslev-Jensen
- 1Odense Research Center for Anaphylaxis (ORCA), Department of Dermatology and Allergy Center, Odense University Hospital, Odense, Denmark
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Gray NJ, Redshaw EL, Isaacs D, Tarzi MD, Smith HE, Frew AJ. Allergy in the elderly: A case note review of referrals to an adult allergy clinic. Clin Exp Allergy 2018; 48:1238-1241. [DOI: 10.1111/cea.13179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 03/22/2018] [Accepted: 04/04/2018] [Indexed: 12/13/2022]
Affiliation(s)
- N. J. Gray
- Department of Allergy & Respiratory Medicine; Royal Sussex County Hospital; Brighton UK
| | - E. L. Redshaw
- Department of Primary Care and Public Health; Brighton & Sussex Medical School; Brighton UK
| | - D. Isaacs
- Department of Primary Care and Public Health; Brighton & Sussex Medical School; Brighton UK
| | - M. D. Tarzi
- Department of Allergy & Respiratory Medicine; Royal Sussex County Hospital; Brighton UK
| | - H. E. Smith
- Department of Primary Care and Public Health; Brighton & Sussex Medical School; Brighton UK
- Family Medicine and Primary Care; Lee Kong Chian School of Medicine; Nanyang Technological University Singapore; Singapore 308232
| | - A. J. Frew
- Department of Allergy & Respiratory Medicine; Royal Sussex County Hospital; Brighton UK
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22
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Grabenhenrich LB, Dölle S, Ruëff F, Renaudin JM, Scherer K, Pföhler C, Treudler R, Koehli A, Mahler V, Spindler T, Lange L, Bilò MB, Papadopoulos NG, Hourihane JOB, Lang R, Fernández-Rivas M, Christoff G, Cichocka-Jarosz E, Worm M. Epinephrine in Severe Allergic Reactions: The European Anaphylaxis Register. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1898-1906.e1. [PMID: 29606638 DOI: 10.1016/j.jaip.2018.02.026] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 02/19/2018] [Accepted: 02/25/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Current guidelines recommend intramuscular administration of epinephrine as the first-line drug for the emergency treatment of severe allergic reactions (anaphylaxis), but no randomized trial evidence supports this consensus. OBJECTIVE We aimed to assess anaphylaxis treatment practices over 10 years, covering several European regions, all allergen sources, and all age groups. METHODS The European Anaphylaxis Register tracks elicitors, symptoms, emergency treatment, diagnostic workups, and long-term counseling for anaphylaxis incidents through web-based data entry from tertiary allergy specialists, covering information from the emergency respondent, patient, tertiary referral, and laboratory/clinical test results. RESULTS We analyzed 10,184 anaphylaxis incidents. In total, 27.1% of patients treated by a health professional received epinephrine and, in total, 10.5% received a second dose. Successful administration was less frequent in German-speaking countries (minimum 19.6%) than in Greece, France, and Spain (maximum 66.7%). Over the last decade, epinephrine administration from a health professional almost doubled to reach 30.6% in 2015-2017, half of which was applied intramuscularly. A total of 14.7% of lay- or self-treated cases were treated with an autoinjector. Of those without treatment, 22.4% carried a device for administration. No change in successful administration by lay emergency respondents was found over the last 10 years. Of the reaction and patient characteristics analyzed, only clinical severity considerably influenced the likelihood of receiving epinephrine, with 66.9% of successful administrations in near-fatal (grade IV) reactions. CONCLUSIONS Despite clear recommendations, only a small proportion of anaphylaxis incidents are treated with epinephrine. We demonstrated a slight increase in treated patients when handled by professionals, but stagnation in lay- or self-treated anaphylaxis. The reaction circumstances, the respondent's professional background, and patient characteristics did not explain which reactions were treated.
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Affiliation(s)
- Linus B Grabenhenrich
- Department of Dermatology, Venerology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Infectious Disease Epidemiology, Robert Koch-Institut, Berlin, Germany
| | - Sabine Dölle
- Department of Infectious Disease Epidemiology, Robert Koch-Institut, Berlin, Germany
| | - Franziska Ruëff
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilian Universität München, Munich, Germany
| | | | - Kathrin Scherer
- Department of Dermatology, Universitätsspital Basel, Basel, Switzerland
| | - Claudia Pföhler
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Regina Treudler
- Department of Dermatology, Venerology and Allergology, Universitätsmedizin Leipzig, Leipzig, Germany
| | - Alice Koehli
- Division of Allergology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Vera Mahler
- Division of Allergology, Paul-Ehrlich-Institut, Langen, Germany
| | - Thomas Spindler
- Klinik für Pädiatrische Pneumologie und Allergologie, Lungenzentrum Süd-West, Wangen im Allgäu, Germany
| | - Lars Lange
- Department of Pediatrics, St. Marien-Hospital, Bonn, Germany
| | - Maria Beatrice Bilò
- Department of Internal Medicine/Allergy Unit, University Hospital Ospedali Riuniti, Ancona, Italy
| | - Nikolaos G Papadopoulos
- 2nd Pediatric Clinic, Allergy Department, University of Athens, Athens, Greece; Division of Infection, Immunity and Respiratory Medicine, Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | | | - Roland Lang
- Universitätsklinik für Dermatologie SALK, Paracelsus medizinische Privatuniversität Salzburg, Salzburg, Austria
| | | | - George Christoff
- Allergy Outpatient Clinic, Tokuda Medical Centre Sofia, Sofia, Bulgaria
| | - Ewa Cichocka-Jarosz
- Department of Pediatrics, Jagiellonian University Medical College, Kraków, Poland
| | - Margitta Worm
- Department of Infectious Disease Epidemiology, Robert Koch-Institut, Berlin, Germany.
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23
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Anaphylaxis in the Workplace. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0155-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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24
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Vetander M, Protudjer JLP, Lilja G, Kull I, Hedlin G, van Hage M, Östblom E, Bergström A, Wickman M. Anaphylaxis to foods in a population of adolescents: incidence, characteristics and associated risks. Clin Exp Allergy 2017; 46:1575-1587. [PMID: 27790764 DOI: 10.1111/cea.12842] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/28/2016] [Accepted: 10/06/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Information about severe reactions to foods in adolescence is limited. OBJECTIVE To describe reactions to foods, including anaphylaxis, with regard to incidence, characteristics and associated risks, among 16-year-olds (adolescents) in a large, population-based birth cohort. METHODS Parent-reported questionnaire data from ages 2-3 months, and 1, 2 and 16 years were used (N = 3153). Anaphylaxis at age 16 years was defined per NIAID/FAAN criteria. Immunoglobulin E (IgE) antibodies to 14 common food and inhalant allergens were analysed at ages 4 (n = 2283) and 16 years (n = 2510). Among adolescents with food-related symptoms (FRS) and for whom blood was available (n = 221), 25 additional food allergen extracts or allergen components were analysed. Associations between reactions to foods, and sensitization and allergic multimorbidity were investigated. RESULTS In the 12 months prior to the 16-year assessment, 8.5% of adolescents had FRS. This included 0.8% (n = 24) adolescents who were classified as having anaphylaxis, yielding an incidence rate of 761/100 000 person-years. One-third of adolescents accessed health care during anaphylaxis. Allergic multimorbidity in infancy, as well as sensitization to foods and airborne allergens at age 4 years, was associated with an increased risk for FRS in adolescence. Peanuts and tree nuts were the most common culprit foods for anaphylaxis, and fruits and vegetables for non-anaphylactic reactions. Adolescents with anaphylaxis were significantly more likely to be sensitized to storage proteins (Ara h 2, Cor a 9, Cor a 14) and to be polysensitized to foods (P < 0.001 vs. non-anaphylactic reactions). CONCLUSIONS AND CLINICAL RELEVANCE The incidence of food-induced anaphylaxis during adolescence in our population-based birth cohort is higher than previously reported. Adolescents with anaphylaxis differ from adolescents with non-anaphylactic FRS with regard to culprit foods and sensitization. Adolescents with previous anaphylaxis are likely to be polysensitized to foods, particularly tree nut and peanut storage proteins, and which warrants consideration at follow-up.
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Affiliation(s)
- M Vetander
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - J L P Protudjer
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - G Lilja
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - I Kull
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - G Hedlin
- Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.,Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - M van Hage
- Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine Solna, Immunology and Allergy Unit, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - E Östblom
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - A Bergström
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - M Wickman
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
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Affiliation(s)
- Ludger Klimek
- Zentrum für Rhinologie & Allergologie, An den Quellen 10, D-65183, Wiesbaden, Deutschland.
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An analysis of anaphylaxis cases at a single pediatric emergency department during a 1-year period. Ann Allergy Asthma Immunol 2017; 118:461-464. [PMID: 28390586 DOI: 10.1016/j.anai.2017.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/06/2017] [Accepted: 02/06/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Case series of anaphylaxis can vary regarding causes, treatments, and follow-up of patients. Unfortunately, case series that are specific to the pediatric population are few. OBJECTIVE To describe confirmed cases of pediatric anaphylaxis in patients presenting to a pediatric hospital emergency department (ED). METHODS We identified all ED visits with the International Classification of Diseases, Ninth Revision (ICD-9) codes 995.XX (allergic reactions) and 989.5 (sting or venom reaction) for 1 calendar year (January 1, 2014, through December 31, 2014). Cases were reviewed by an allergist and an emergency medicine physician to identify true anaphylaxis cases using National Institute of Health/National Institute of Allergy and Infectious Diseases criteria. Any questionable or debatable cases were evaluated and adjudicated by a second allergist. RESULTS We identified 927 unique ED visits. Of these visits, 40 were determined to definitively meet anaphylaxis criteria. Median age of the patients was 6.5 years. A total of 70% of patients were male, and 80% were African American. Causes included foods (65%), venom or insect sting (12.5%), and medications (5%), and 17.5% were idiopathic. All patients had multiorgan involvement, with 98% having skin involvement, 78% having lower respiratory tract symptoms, and 40% having gastrointestinal symptoms. There were no deaths. Only 33% of patients received epinephrine at some point in their care. Only 12 patients were referred to an allergist, and only 4 of these were actually seen by an allergist. CONCLUSION At our center, foods are the most common trigger for pediatric anaphylaxis. Patients continue to be undertreated, and referral to an allergist from the ED is rare.
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Registries as useful tools in characterization of allergic manifestations. Curr Opin Allergy Clin Immunol 2017; 16:250-6. [PMID: 27031675 DOI: 10.1097/aci.0000000000000265] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Registries are useful to discover the applicability of data generated from randomized clinical trials (RCTs) into daily practice, and to search for real-life data usually not covered by them. RECENT FINDINGS In allergy, registry research brought clues to important epidemiological and clinical problems hardly accessible with other methods. The increase in the asthma prevalence in Sweden in contrast with stabilization in Denmark; the association of the prevalence of asthma and environmental factors; the knowledge of existing rhinitis international guidelines, but the poorly complacence of some of their recommendations; the low epinephrine use in anaphylaxis and the difference among European and Latin American elicitors; the predominance of β lactams or NSAIDs as drug hypersensitivity reactions inducers in different regions; the fact that most of the hereditary angioedema patients were receiving long-term prophylaxis with attenuated androgens; all the mentioned are clear examples of relevant and important data provided by current registries. SUMMARY Registries in allergy enlighten knowledge in areas not covered by classical investigational methods. As the number and importance of registries is growing, its contribution to the knowledge and management of allergic diseases will increase in the near future.
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Munblit D, Treneva M, Korsunskiy I, Asmanov A, Pampura A, Warner JO. A national survey of Russian physicians' knowledge of diagnosis and management of food-induced anaphylaxis. BMJ Open 2017; 7:e015901. [PMID: 28729318 PMCID: PMC5541513 DOI: 10.1136/bmjopen-2017-015901] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Food allergy is an increasing burden worldwide and is a common problem within paediatric populations, affecting 5%-8% of children. Anaphylaxis caused by food proteins is a potentially life-threatening condition and all healthcare practitioners should be aware of its recognition and management. Russia is the largest country in Europe but it is still unknown whether physicians are prepared to diagnose and manage food-induced anaphylaxis effectively. We aimed to examine physicians' knowledge of diagnosis and management of food-induced anaphylaxis. SETTING, POPULATION AND OUTCOMES A survey was designed and published online at VrachiRF.ru website (for registered Russian-speaking practicing physicians). We obtained information on respondents' clinical settings, experience and specialty. Survey questions were based on a characteristic clinical scenario of anaphylaxis due to food ingestion. Outcome measures consisted of correct answers to the anaphylaxis diagnosis and management questions. RESULTS From a total of 707 of physicians accessed in the survey, 315 (45%) responded to the clinical scenario. 16 respondents reported training in allergy-immunology and have been excluded from the analysis, leaving the final sample size of 299. Respondents were paediatricians (68%) and other specialties adult physicians (32%). Overall, 100 (33%) of respondents diagnosed anaphylaxis, but only 29% of those making the correct diagnosis administered adrenalin (1:1000) intramuscular. Respondents working in secondary/tertiary clinics diagnosed anaphylaxis significantly more often (p=0.04) when compared with primary care/private practice physicians. This difference was also apparent as the most important influence on responses in the multivariate analysis. CONCLUSIONS In this national sample of Russian physicians, we found poor knowledge in both anaphylaxis diagnosis and management. Our data show that the chance of being properly diagnosed with anaphylaxis is 33% and being appropriately treated with adrenalin is 10%. These findings highlight lack of anaphylaxis knowledge among Russian physicians, both paediatricians and other specialists and illustrates the urgent need for allergy/anaphylaxis training.
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Affiliation(s)
- Daniel Munblit
- Department of Paediatrics, Imperial College London, London, UK
- Faculty of Pediatrics, I.M. Sechenov First Moscow State Medical University, Russia
- International Inflammation (in-FLAME) Network of the World Universities Network, Perth, WA, Australia
| | - Marina Treneva
- International Inflammation (in-FLAME) Network of the World Universities Network, Perth, WA, Australia
- Allergy Department, Veltischev Clinical Pediatric Research Institute of Pirogov Russian National Research Medical University, Russia
| | - Ilya Korsunskiy
- Faculty of Pediatrics, I.M. Sechenov First Moscow State Medical University, Russia
| | - Alan Asmanov
- Allergy Department, Veltischev Clinical Pediatric Research Institute of Pirogov Russian National Research Medical University, Russia
| | - Alexander Pampura
- Allergy Department, Veltischev Clinical Pediatric Research Institute of Pirogov Russian National Research Medical University, Russia
| | - John O Warner
- Department of Paediatrics, Imperial College London, London, UK
- International Inflammation (in-FLAME) Network of the World Universities Network, Perth, WA, Australia
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care for NW London, London, UK
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Benedé S, Garrido-Arandia M, Martín-Pedraza L, Bueno C, Díaz-Perales A, Villalba M. Multifactorial Modulation of Food-Induced Anaphylaxis. Front Immunol 2017; 8:552. [PMID: 28559894 PMCID: PMC5432630 DOI: 10.3389/fimmu.2017.00552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 04/25/2017] [Indexed: 01/26/2023] Open
Abstract
Prevalence of food-induced anaphylaxis increases progressively and occurs in an unpredictable manner, seriously affecting the quality of life of patients. Intrinsic factors including age, physiological, and genetic features of the patient as well as extrinsic factors such as the intake of drugs and exposure to environmental agents modulate this disorder. It has been proven that diseases, such as mastocytosis, defects in HLA, or filaggrin genes, increase the risk of severe allergic episodes. Certain allergen families such as storage proteins, lipid transfer proteins, or parvalbumins have also been linked to anaphylaxis. Environmental factors such as inhaled allergens or sensitization through the skin can exacerbate or trigger acute anaphylaxis. Moreover, the effect of dietary habits such as the early introduction of certain foods in the diet, and the advantage of the breastfeeding remain as yet unresolved. Interaction of allergens with the intestinal cell barrier together with a set of effector cells represents the primary pathways of food-induced anaphylaxis. After an antigen cross-links the IgEs on the membrane of effector cells, a complex intracellular signaling cascade is initiated, which leads cells to release preformed mediators stored in their granules that are responsible for the acute symptoms of anaphylaxis. Afterward, they can also rapidly synthesize lipid compounds such as prostaglandins or leukotrienes. Cytokines or chemokines are also released, leading to the recruitment and activation of immune cells in the inflammatory microenvironment. Multiple factors that affect food-induced anaphylaxis are discussed in this review, paying special attention to dietary habits and environmental and genetic conditions.
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Affiliation(s)
- Sara Benedé
- Dpto. Bioquímica y Biología Molecular I, Universidad Complutense de Madrid, Madrid, Spain
| | - María Garrido-Arandia
- Centro de Biotecnología y Genómica de Plantas (UPM-INIA), Campus de Montegancedo, Pozuelo de Alarcón, Madrid, Spain
| | - Laura Martín-Pedraza
- Dpto. Bioquímica y Biología Molecular I, Universidad Complutense de Madrid, Madrid, Spain
| | - Cristina Bueno
- Dpto. Bioquímica y Biología Molecular I, Universidad Complutense de Madrid, Madrid, Spain
| | - Araceli Díaz-Perales
- Centro de Biotecnología y Genómica de Plantas (UPM-INIA), Campus de Montegancedo, Pozuelo de Alarcón, Madrid, Spain
| | - Mayte Villalba
- Dpto. Bioquímica y Biología Molecular I, Universidad Complutense de Madrid, Madrid, Spain
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Fiedler C, Miehe U, Treudler R, Kiess W, Prenzel F. Long-Term Follow-Up of Children after Venom Immunotherapy: Low Adherence to Anaphylaxis Guidelines. Int Arch Allergy Immunol 2017; 172:167-172. [DOI: 10.1159/000458707] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 01/30/2017] [Indexed: 11/19/2022] Open
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Lange L, Lasota L, Finger A, Vlajnic D, Büsing S, Meister J, Broekaert I, Pfannenstiel C, Friedrichs F, Price M, Trendelenburg V, Niggemann B, Beyer K. Ana o 3-specific IgE is a good predictor for clinically relevant cashew allergy in children. Allergy 2017; 72:598-603. [PMID: 27644013 DOI: 10.1111/all.13050] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Component-resolved diagnostics using specific IgE to 2 S albumins has shown to be a valuable new option in diagnostic procedure. Ana o 3 is a 2 S albumin from cashew. The aim of this study was to investigate the role of Ana o 3-specific serum IgE in the diagnosis of cashew allergy and to identify cut-off levels to replace oral food challenges. Moreover, the value of additional determination of total IgE has been investigated. METHODS In a multicentre study, we analysed specific IgE to cashew extract and Ana o 3 as well as total IgE in children with suspected cashew allergy using the ImmunoCAP-FEIA and a standardized diagnostic procedure including oral challenges where indicated. RESULTS A total of 61 patients were included in the study. Forty-two were allergic to cashew, and 19 were tolerant. In receiver operating curves, Ana o 3 discriminates between allergic and tolerant children better than cashew-specific IgE with an area under the curve of 0.94 vs 0.78. The ratio of Ana o 3-specific IgE to total IgE did not further improve the diagnostic procedure. Probability curves for Ana o 3-specific IgE have been calculated, and a 95% probability could be estimated at 2.0 kU/l. CONCLUSION Specific IgE to Ana o 3 is a valuable tool for the diagnosis of cashew allergy. Considering its positive predictive value, it might allow to make a considerable number of oral challenges superfluous.
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Affiliation(s)
- L. Lange
- Department of Pediatrics; St. Marien-Hospital; Bonn Germany
| | - L. Lasota
- Institute of Medical Biometry; Informatics und Epidemiology (IMBIE); Bonn Germany
| | - A. Finger
- Department of Pediatrics; St. Marien-Hospital; Bonn Germany
| | - D. Vlajnic
- Department of Pediatrics; St. Marien-Hospital; Bonn Germany
| | - S. Büsing
- Children's Hospital; Osnabrück Germany
| | - J. Meister
- Department for Pediatrics; Helios Klinikum; Aue Germany
| | - I. Broekaert
- Children's Hospital; University of Cologne; Cologne Germany
| | | | | | - M. Price
- Children's Hospital; Hannover Medical School; Hannover Germany
| | - V. Trendelenburg
- Department of Pediatric Pneumology and Immunology; Charité-Universitätsmedizin; Berlin Germany
| | - B. Niggemann
- Department of Pediatric Pneumology and Immunology; Charité-Universitätsmedizin; Berlin Germany
| | - K. Beyer
- Department of Pediatric Pneumology and Immunology; Charité-Universitätsmedizin; Berlin Germany
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Versluis A, van Os-Medendorp H, Kruizinga AG, Blom WM, Houben GF, Knulst AC. Cofactors in allergic reactions to food: physical exercise and alcohol are the most important. IMMUNITY INFLAMMATION AND DISEASE 2016; 4:392-400. [PMID: 27980774 PMCID: PMC5134724 DOI: 10.1002/iid3.120] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 07/07/2016] [Accepted: 07/13/2016] [Indexed: 12/03/2022]
Abstract
Introduction Involvement of cofactors, like physical exercise, alcohol consumption and use of several types of medication, are associated with more severe food allergic symptoms. However, there is limited evidence on how often cofactors play a role in food allergic reactions. The study aimed to get more insight into the frequency of exposure to cofactors and how often cofactors are associated with more severe symptoms in food allergic patients. Methods A questionnaire was completed by patients visiting the Allergology outpatient clinic. Patients with food allergy were included. Outcome measures were the frequency of medication use of medication groups that might act as cofactor and the frequency that physical exercise, alcohol consumption and use of analgesics are associated with more severe food allergic symptoms. Results Four hundred ninety‐six patients were included in the study. The frequency with which patients used one or more types of medication that might act as cofactors was 7.7%: antacids/acid neutralizing medication (5%), NSAIDs (2%), beta blockers (0.6%), angiotensin‐converting enzyme inhibitors (0.6%), and angiotensin receptor blockers (0.2%). Of all patients, 13% reported more severe symptoms to food after involvement of one or more of the cofactors: physical exercise (10%), alcohol consumption (5%), and use of analgesics (0.6%). Sixty‐five percent did not know if these cofactors caused more severe symptoms; 22% reported that these cofactors had no effect. Conclusions Only a small percentage of patients (7.7%) used medication that might aggravate food allergic reactions. Physical exercise and alcohol consumption were the most frequently reported cofactors, but occurring still in only 10% or less.
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Safety and tolerability during build-up phase of a rush venom immunotherapy. Ann Allergy Asthma Immunol 2016; 116:360-5. [PMID: 27055991 DOI: 10.1016/j.anai.2016.02.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 02/16/2016] [Accepted: 02/22/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Safety and tolerability of venom immunotherapy (VIT) in patients with concomitant disease and comedications, especially β-blockers (BBs) and angiotensin-converting enzyme inhibitors (ACEIs), are under discussion. OBJECTIVE To identify risk factors for the occurrence of systemic reactions (SRs) during the build-up phase of a 3-day rush VIT with focus on comorbidities and related comedications. METHODS Data of 175 three-day rush VIT courses (Vespula venom, n = 161; honeybee venom, n = 14) were analyzed. Starting with 0.02 μg of venom, the maintenance dose of 100 μg was reached in 15-dose increments within 3 days. Local reactions (LRs) and SRs were documented during the build-up phase. Comorbidities and related comedications were registered. Univariate, bivariate, and multivariate data analysis was performed. RESULTS During the 3-day rush VIT, an LR was seen in 74 (42.3%) of 175, a large LR (>10-cm diameter) in 82 (46.9%) of 175, and SRs in 19 (10.9%) of 175 VIT courses. Multivariate logistic regression revealed that female sex (P = .01), immunotherapy with honeybee venom (P = .003), and accompanying ACEI medication (P = .03) were independent predictors of the development of SRs during the build-up phase of VIT. CONCLUSION This study revealed that female sex, honeybee VIT, and ACEI use independent predictors for SRs.
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Turner PJ, Baumert JL, Beyer K, Boyle RJ, Chan CH, Clark AT, Crevel RWR, DunnGalvin A, Fernández-Rivas M, Gowland MH, Grabenhenrich L, Hardy S, Houben GF, O'B Hourihane J, Muraro A, Poulsen LK, Pyrz K, Remington BC, Schnadt S, van Ree R, Venter C, Worm M, Mills ENC, Roberts G, Ballmer-Weber BK. Can we identify patients at risk of life-threatening allergic reactions to food? Allergy 2016; 71:1241-55. [PMID: 27138061 DOI: 10.1111/all.12924] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 12/31/2022]
Abstract
Anaphylaxis has been defined as a 'severe, life-threatening generalized or systemic hypersensitivity reaction'. However, data indicate that the vast majority of food-triggered anaphylactic reactions are not life-threatening. Nonetheless, severe life-threatening reactions do occur and are unpredictable. We discuss the concepts surrounding perceptions of severe, life-threatening allergic reactions to food by different stakeholders, with particular reference to the inclusion of clinical severity as a factor in allergy and allergen risk management. We review the evidence regarding factors that might be used to identify those at most risk of severe allergic reactions to food, and the consequences of misinformation in this regard. For example, a significant proportion of food-allergic children also have asthma, yet almost none will experience a fatal food-allergic reaction; asthma is not, in itself, a strong predictor for fatal anaphylaxis. The relationship between dose of allergen exposure and symptom severity is unclear. While dose appears to be a risk factor in at least a subgroup of patients, studies report that individuals with prior anaphylaxis do not have a lower eliciting dose than those reporting previous mild reactions. It is therefore important to consider severity and sensitivity as separate factors, as a highly sensitive individual will not necessarily experience severe symptoms during an allergic reaction. We identify the knowledge gaps that need to be addressed to improve our ability to better identify those most at risk of severe food-induced allergic reactions.
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Affiliation(s)
- P. J. Turner
- Section of Paediatrics (Allergy and Infectious Diseases) & MRC and Asthma UK Centre in Allergic Mechanisms of Asthma; Imperial College London; London UK
| | - J. L. Baumert
- Food Allergy Research and Resource Program; Department of Food Science and Technology; University of Nebraska; Lincoln NE USA
| | - K. Beyer
- Department of Pediatric Pneumology and Immunology; Charité Universitätsmedizin; Berlin Germany
| | - R. J. Boyle
- Section of Paediatrics (Allergy and Infectious Diseases) & MRC and Asthma UK Centre in Allergic Mechanisms of Asthma; Imperial College London; London UK
| | | | - A. T. Clark
- Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - R. W. R. Crevel
- Safety and Environmental Assurance Centre; Unilever; Colworth Science Park; Sharnbrook Bedford UK
| | - A. DunnGalvin
- Applied Psychology and Paediatrics and Child Health; University College Cork; Cork Ireland
| | | | | | - L. Grabenhenrich
- Institute for Social Medicine; Epidemiology and Health Economics; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - S. Hardy
- Food Standards Agency; London UK
| | | | - J. O'B Hourihane
- Paediatrics and Child Health; University College Cork; Cork Ireland
| | - A. Muraro
- Department of Paediatrics; Centre for Food Allergy Diagnosis and Treatment; University of Padua; Veneto Italy
| | - L. K. Poulsen
- Allergy Clinic; Copenhagen University Hospital at Gentofte; Copenhagen Denmark
| | - K. Pyrz
- Applied Psychology and Paediatrics and Child Health; University College Cork; Cork Ireland
| | | | - S. Schnadt
- German Allergy and Asthma Association (Deutscher Allergie- und Asthmabund (DAAB)); Mönchengladbach Germany
| | - R. van Ree
- Departments of Experimental Immunology and of Otorhinolaryngology; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - C. Venter
- School of Health Sciences and Social Work; University of Portsmouth; Portsmouth UK
- The David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Isle of Wight UK
| | - M. Worm
- Allergy-Center Charité; Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - E. N. C. Mills
- Institute of Inflammation and Repair; Manchester Academic Health Science Centre; Manchester Institute of Biotechnology; The University of Manchester; Manchester UK
| | - G. Roberts
- The David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Isle of Wight UK
- NIHR Respiratory Biomedical Research Unit; University Hospital Southampton NHS Foundation Trust and Human Development and Health Academic Unit; University of Southampton Faculty of Medicine; Southampton UK
| | - B. K. Ballmer-Weber
- Allergy Unit; Department of Dermatology; University Hospital; University Zürich; Zürich Switzerland
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Prevention of Anaphylaxis Based on Risk Factors and Cofactors. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0095-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Badellino H, Jares E. Advances in Food-Induced Anaphylaxis. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0093-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jiang N, Yin J, Wen L, Li H. Characteristics of Anaphylaxis in 907 Chinese Patients Referred to a Tertiary Allergy Center: A Retrospective Study of 1,952 Episodes. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2016; 8:353-61. [PMID: 27126729 PMCID: PMC4853513 DOI: 10.4168/aair.2016.8.4.353] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Revised: 09/04/2015] [Accepted: 10/06/2015] [Indexed: 12/04/2022]
Abstract
Purpose Comprehensive evaluation of anaphylaxis in China is currently lacking. In this study, we characterized the clinical profiles, anaphylactic triggers, and emergency treatment in pediatric and adult patients. Methods Outpatients diagnosed with "anaphylaxis" or "severe allergic reactions" in the Department of Allergy, Peking Union Medical College Hospital from January 1, 2000 to June 30, 2014 were analyzed retrospectively. Results A total of 1,952 episodes of anaphylaxis in 907 patients were analyzed (78% were adults and 22% were children). Foods are the most common cause (77%), followed by idiopathic etiologies (15%), medications (7%) and insects (0.6%). In food-induced anaphylaxis, 62% (13/21) of anaphylaxis in infants and young children (0-3 years of age) were triggered by milk, 59% (36/61) of anaphylaxis in children (4-9 years of age) were triggered by fruits/vegetables, while wheat was the cause of anaphylaxis in 20% (56/282) of teenagers (10-17 years of age) and 42% (429/1,016) in adults (18-50 years of age). Mugwort pollen sensitization was common in patients with anaphylaxis induced by spices, fruits/vegetables, legume/peanuts, and tree nuts/seeds, with the prevalence rates of 75%, 67%, 61%, and 51%, respectively. Thirty-six percent of drug-induced anaphylaxis was attributed to traditional Chinese Medicine. For patients receiving emergency care, only 25% of patients received epinephrine. Conclusions The present study showed that anaphylaxis appeared to occur more often in adults than in infants and children, which were in contrast to those found in other countries. In particular, wheat allergens played a prominent role in triggering food-induced anaphylaxis, followed by fruits/vegetables. Traditional Chinese medicine was a cause of drug-induced anaphylaxis. Furthermore, exercise was the most common factor aggravating anaphylaxis. Education regarding the more aggressive use of epinephrine in the emergency setting is clearly needed.
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Affiliation(s)
- Nannan Jiang
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jia Yin
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Liping Wen
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hong Li
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Grabenhenrich L, Lange L, Härtl M, Kalb B, Ziegert M, Finger A, Harandi N, Schlags R, Gappa M, Puzzo L, Stephan V, Heigele T, Büsing S, Ott H, Niggemann B, Beyer K. The component-specific to total IgE ratios do not improve peanut and hazelnut allergy diagnoses. J Allergy Clin Immunol 2016; 137:1751-1760.e8. [PMID: 27087317 DOI: 10.1016/j.jaci.2016.01.043] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 11/17/2015] [Accepted: 01/13/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Specific IgE measurement predicts the outcome of oral food challenges with considerable uncertainty when evaluating food allergy. OBJECTIVE Our aim was to assess whether accounting for the ratio of component- or allergen-specific to total IgE can improve this prediction. METHODS This multicenter study collected blood samples from children with suspected peanut or hazelnut allergy referred to allergy specialist clinics for food challenges. Specific IgE to peanuts, hazelnuts, and their components (Ara h 1, Ara h 2, Ara h 3, Ara h 8, Cor a 1, Cor a 8, Cor a 9, and Cor a 14) and total IgE levels were determined by using the ImmunoCAP-FEIA. Specific to total IgE ratios were compared with raw IgE levels in terms of discrimination and prediction. RESULTS Eighty-eight (43%) of 207 children with suspected peanut allergy and 44 (31%) of 142 children with suspected hazelnut allergy had symptoms during food challenge. Discrimination was similar for raw and ratio measures: areas under the curve of 0.93 for Ara h 2-specific IgE versus 0.92 for the Ara h 2-specific/total IgE ratio and 0.89 for Cor a 14-specific IgE versus 0.87 for the Cor a 14-specific/total IgE ratio. The probability for a positive peanut challenge with 0.35 kU/L Ara h 2-specific IgE was 16% when the total IgE level was greater than 500 kU/L compared with 51%/48% for low/medium total IgE levels (<100/100-500 kU/L). A positive hazelnut challenge with 0.35 kU/L Cor a 14-specific IgE was estimated in 7% when total IgE levels were high compared with 34%/32% with low/medium total IgE levels. CONCLUSIONS Raw Ara h 2- and Cor a 14-specific IgE levels were the best single predictors for pediatric peanut and hazelnut allergies, suggesting the omission of challenges at very high levels. Calculating ratio measures did not improve prediction in this population. However, estimation of individual probabilities for challenge outcomes could be supported by total IgE levels because high levels might indicate lower probabilities at a given component-specific IgE level.
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Affiliation(s)
- Linus Grabenhenrich
- Charité - Universitätsmedizin Berlin, Institute for Social Medicine, Epidemiology and Health Economics, Berlin, Germany.
| | - Lars Lange
- St Marien-Hospital, Department for Pediatrics, Bonn, Germany
| | - Magdalena Härtl
- Charité - Universitätsmedizin Berlin, Department of Pediatric Pneumology and Immunology, Berlin, Germany
| | - Birgit Kalb
- Charité - Universitätsmedizin Berlin, Department of Pediatric Pneumology and Immunology, Berlin, Germany
| | - Mandy Ziegert
- German Red Cross Hospital, Department for Pediatrics, Berlin, Germany
| | - Antje Finger
- St Marien-Hospital, Department for Pediatrics, Bonn, Germany
| | | | | | - Monika Gappa
- Marien-Hospital, Children's Department, Wesel, Germany
| | - Letizia Puzzo
- Marien-Hospital, Children's Department, Wesel, Germany
| | | | | | - Susanne Büsing
- Children's Hospital Osnabrück, Department for Pediatrics, Osnabrück, Germany
| | - Hagen Ott
- Children's Hospital Auf der Bult, Hannover, Germany
| | - Bodo Niggemann
- Charité - Universitätsmedizin Berlin, Department of Pediatric Pneumology and Immunology, Berlin, Germany; German Red Cross Hospital, Department for Pediatrics, Berlin, Germany
| | - Kirsten Beyer
- Charité - Universitätsmedizin Berlin, Department of Pediatric Pneumology and Immunology, Berlin, Germany; Icahn School of Medicine at Mount Sinai, New York, NY
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Baker TW, Forester JP, Johnson ML, Sikora JM, Stolfi A, Stahl MC. Stinging insect identification: Are the allergy specialists any better than their patients? Ann Allergy Asthma Immunol 2016; 116:431-4. [PMID: 26993171 DOI: 10.1016/j.anai.2016.01.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 01/23/2016] [Accepted: 01/28/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND It has been reported that the general population is not skillful at identifying stinging insects with the exception of the honeybee. No information is available to evaluate allergy physicians' accuracy with stinging insect identification. OBJECTIVE To measure the accuracy of allergists' ability to identify stinging insects and assess their common practices for evaluating individuals with suspected insect hypersensitivity. METHODS A picture-based survey and a dried specimen insect box were constructed to determine allergists' and nonallergists' accuracy in identifying insects. Allergists attending the 2013 American College of Allergy, Asthma, and Immunology meeting were invited to participate in the study. Common practice approaches for evaluating individuals with stinging insect hypersensitivity were also investigated using a brief questionnaire. RESULTS Allergy physicians are collectively better at insect identification than nonallergists. Overall, the mean (SD) number of correct responses for nonallergists was 5.4 (2.0) of a total of 10. This score was significantly lower than the score for allergists (6.1 [2.0]; P = .01) who participated in the study. Most allergists (78.5%) test for all stinging insects and use skin testing (69.5%) as the initial test of choice for evaluating individuals with insect hypersensitivity. CONCLUSION Overall, allergists are more skilled at Hymenoptera identification. Most allergy specialists reported testing for all stinging insects when evaluating insect hypersensitivity, and skin testing was the preferred testing method in nearly 70% of allergists. These data support the practice parameter's recommendation to consider testing for all flying Hymenoptera insects during venom evaluation, which most of the participating allergists surveyed incorporate into their clinical practice.
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Affiliation(s)
| | | | | | | | - Adrienne Stolfi
- Department of Pediatrics, Wright State University, Dayton, Ohio
| | - Mark C Stahl
- The Children's Hospital of San Antonio, San Antonio, Texas
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40
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Affiliation(s)
- B. Niggemann
- Division of Pediatric Pneumology and Immunology; University Children's Hospital Charité; Berlin Germany
| | - K. Beyer
- Division of Pediatric Pneumology and Immunology; University Children's Hospital Charité; Berlin Germany
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Gomes ER, Brockow K, Kuyucu S, Saretta F, Mori F, Blanca-Lopez N, Ott H, Atanaskovic-Markovic M, Kidon M, Caubet JC, Terreehorst I. Drug hypersensitivity in children: report from the pediatric task force of the EAACI Drug Allergy Interest Group. Allergy 2016; 71:149-61. [PMID: 26416157 DOI: 10.1111/all.12774] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2015] [Indexed: 12/22/2022]
Abstract
When questioned, about 10% of the parents report suspected hypersensitivity to at least one drug in their children. However, only a few of these reactions can be confirmed as allergic after a diagnostic workup. There is still a lack of knowledge on drug hypersensitivity (DH) epidemiology, clinical spectrum, and appropriate diagnostic methods particularly in children. Meanwhile, the tools used for DH management in adults are applied also for children. Whereas this appears generally acceptable, some aspects of DH and management differ with age. Most reactions in children are still attributed to betalactams. Some manifestations, such as nonsteroidal anti-inflammatory drug-associated angioedema and serum sickness-like reactions, are more frequent among young patients as compared to adults. Risk factors such as viral infections are particularly frequent in children, making the diagnosis challenging. The practicability and validity of skin test and other diagnostic procedures need further assessment in children. This study presents an up-to-date review on epidemiology, clinical spectrum, diagnostic tools, and current management of DH in children. A new general algorithm for the study of these reactions in children is proposed. Data are presented focusing on reported differences between pediatric and adult patients, also identifying unmet needs to be addressed in further research.
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Affiliation(s)
- E. R. Gomes
- Allergology Department; Centro Hospitalar do Porto; Porto Portugal
| | - K. Brockow
- Division Environmental Dermatology and Allergology Helmholtz Zentrum München/TUM; Department of Dermatology und AllergologyBiederstein; Technical University Munich; Munich Germany
| | - S. Kuyucu
- Department of Pediatric Allergy and Clinical Immunology; Faculty of Medicine; Mersin University; Mersin Turkey
| | - F. Saretta
- Pediatric Department; Hospital of Palmanova; A.S.S.5 ‘Bassa Friulana’; Palmanova UD Italy
| | - F. Mori
- Allergy Unit; Department of Pediatric; Anna Meyer Children's Hospital; University of Florence; Florence Italy
| | - N. Blanca-Lopez
- Allergy Department; Infanta Leonor University Hospital; Madrid Spain
| | - H. Ott
- Division of Pediatric Dermatology; Children's Hospital Auf der Bult; Hannover Germany
| | - M. Atanaskovic-Markovic
- University Children's Hospital of Belgrade; Medical Faculty University of Belgrade; Belgrade Serbia
| | - M. Kidon
- Allergy and Clinical Immunology Unit and Institute for Pediatric Pulmonology and National CF Center; Safra Children's Hospital; Tel Hashomer Israel
| | - J.-C. Caubet
- Division of Pediatric Allergy; University Hospital of Geneva; Geneva Switzerland
| | - I. Terreehorst
- Department of ENT and Pediatrics; AMC; Amsterdam The Netherlands
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Kofaktoren bei Soforttypreaktionen. ALLERGOLOGIE 2016. [DOI: 10.1007/978-3-642-37203-2_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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43
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Brockow K, Ring J, Scheewe S, Staab D. Schulungen. ALLERGOLOGIE 2016. [DOI: 10.1007/978-3-642-37203-2_62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ruffoni S, Barberi S, Bernardo L, Ferrara F, Furgani A, Tosca MA, Schiavetti I, Ciprandi G. Anaphylaxis in pediatric population: A 1-year survey on the Medical Emergency Service in Liguria, Italy. Int J Immunopathol Pharmacol 2015; 28:590-594. [PMID: 25899548 DOI: 10.1177/0394632015580909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 03/09/2015] [Indexed: 10/23/2023] Open
Abstract
Anaphylaxis is a severe, life-threatening, generalized, or systemic hypersensitivity reaction. The diagnosis is mainly based on a clinical ground. This study aimed to evaluate the records of both phone calls and medical visits for anaphylaxis managed by the Liguria Medical Emergency Service (MES) in a pediatric population, occurred during 2013. The phone call is managed at each center and classified according to a level of care intensity and a presumed level of criticality, according to established criteria. Criticality is then re-evaluated (detected criticality) at the end of the medical visit following the same score adding the black code for patients who died. Most of the phone calls (86) to the MES were recorded in summer (40.7%), followed by spring (26.7%), autumn (16.3%), and winter (16.3%). Forty-eight patients (55.8%) were male. Anaphylaxis was confirmed in about half of patients. In addition, almost all subjects (97.7%) were referred to the Emergency Room. In conclusion, the present study shows that anaphylaxis represents a serious and relevant medical problem in the pediatric population and should be ever carefully managed.
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Affiliation(s)
- Silvano Ruffoni
- Emergency Department, IRCCS-Azienda Ospedaliera Universitaria San Martino, Genova, Italy
| | | | - Luca Bernardo
- Department of Pediatrics, Fatebenefratelli Hospital, Milan, Italy
| | | | - Andrea Furgani
- Emergency Department, IRCCS-Azienda Ospedaliera Universitaria San Martino, Genova, Italy
| | - Maria Angela Tosca
- Pulmonary Disease and Allergy Unit, Istituto Giannina Gaslini, Genova, Italy
| | | | - Giorgio Ciprandi
- Medicine Department, IRCCS-Azienda Ospedaliera Universitaria San Martino, Genova, Italy
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Abstract
Food allergies are increasing in prevalence. In order for pediatric clinicians to appropriately diagnose and manage food allergies, the characteristic signs and symptoms of these potentially severe reactions must be recognized. Unlike nonimmunologic adverse food reactions (such as lactose intolerance and food poisoning), food allergies by definition are immune-mediated responses that occur reproducibly on food ingestion. The varying clinical presentations of food allergy include IgE-mediated disorders, mixed IgE- and cell-mediated disorders, and cell-mediated food allergies. This review describes the clinical manifestations of each of these categories of food allergy, with special emphasis on recognition of food-induced anaphylaxis.
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Affiliation(s)
- Hemant P Sharma
- Division of Allergy and Immunology, Children's National Health System, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| | - Shweta Bansil
- Division of Allergy and Immunology, Children's National Health System, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Burcin Uygungil
- Division of Allergy and Immunology, Children's National Health System, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Kilger M, Range U, Vogelberg C. Acute and preventive management of anaphylaxis in German primary school and kindergarten children. BMC Pediatr 2015; 15:159. [PMID: 26471996 PMCID: PMC4608188 DOI: 10.1186/s12887-015-0477-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 10/06/2015] [Indexed: 12/31/2022] Open
Abstract
Background Anaphylaxis is a severe, life-threatening situation. However, little is known about real-life anaphylactic management in children, especially in kindergarten and school settings, where a large number of anaphylaxes take place. Methods Parents, school teachers and child-care providers of 86 primary schools and kindergartens in the city of Dresden, Germany, received questionnaires to report their experience with anaphylaxis in children. The main foci of interest were symptoms, allergens, sites of occurrence, acute treatment and emergency sets. Results Out of 6352 returned questionnaires, 87 cases of anaphylaxis were identified. Prevalence was calculated at 1.5 %. Average age of the patients was 7 years, 58 % were boys. The majority of reactions occurred at home (67 %/58 children). Fourty seven percent (41 children) had recurrent episodes of anaphylaxis. Eighty two percent (71 children) showed cutaneous symptoms, 40 % (35 children) respiratory symptoms, 29 % (25 children) gastrointestinal symptoms, and 3.4 % (3 children) cardiovascular symptoms. Fourty seven percent were classified as mild reactions. Foods were the most common cause (60 %/52 cases). Out of these 52, tree-nuts (23 %/12 cases) and peanuts (16 %/8 cases) were the most frequent triggers. Sixty percent (52 cases) of reactions were treated by a physician, 35 % (30 cases) were treated by non-medical professionals only. Fifty one percent (44 children) received antihistamines, 37 % (32 children) corticosteroids, 1 % (1 child) intramuscular adrenaline. Sixty one percent of children (53 cases) received an emergency kit. Content were corticosteroids (70 %/37 cases) and antihistamines (62 %/33 cases). Adrenaline auto-injectors were prescribed to 26 % (14 cases). Concerning school and kindergarten-staff, 13 % of the child-care providers had no knowledge about the emergency kit’s content, compared to 34 % of teachers. Conclusions This study might support the impression of severe under-treatment of anaphylactic children in the use of adrenaline and prescription of incomplete equipped emergency sets. Knowledge of school and kindergarten staff must be improved through enhanced education. Electronic supplementary material The online version of this article (doi:10.1186/s12887-015-0477-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Magdalena Kilger
- Pediatric Department, TU Dresden, University Hospital Carl Gustav Carus Dresden, Dresden, Germany.
| | - Ursula Range
- Institute for Medical Informatics and Biometry (IMB), Medical Faculty Carl Gustav Carus, Dresden, Germany.
| | - Christian Vogelberg
- Pediatric Department, TU Dresden, University Hospital Carl Gustav Carus Dresden, Dresden, Germany.
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47
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Cutaneous and Systemic Mastocytosis in Children: A Risk Factor for Anaphylaxis? Curr Allergy Asthma Rep 2015; 15:22. [DOI: 10.1007/s11882-015-0525-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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48
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Tosca MA, Pistorio A, Accogli A, Rossi GA, Ciprandi G. Food anaphylaxis in children: Peculiarity of characteristics. Allergol Immunopathol (Madr) 2015; 43:421-3. [PMID: 25088673 DOI: 10.1016/j.aller.2014.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/08/2014] [Accepted: 04/24/2014] [Indexed: 01/22/2023]
Affiliation(s)
- M A Tosca
- Pulmonary Disease and Allergy Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - A Pistorio
- Epidemiology and Biostatistics Service, Istituto Giannina Gaslini, Genoa, Italy
| | - A Accogli
- Pulmonary Disease and Allergy Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - G A Rossi
- Pulmonary Disease and Allergy Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - G Ciprandi
- Medicine Department, IRCCS - Azienda Ospedaliera Universitaria San Martino, Genoa, Italy.
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Alqurashi W, Stiell I, Chan K, Neto G, Alsadoon A, Wells G. Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis. Ann Allergy Asthma Immunol 2015; 115:217-223.e2. [PMID: 26112147 DOI: 10.1016/j.anai.2015.05.013] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 05/07/2015] [Accepted: 05/16/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Epidemiologic data regarding biphasic reactions in children with anaphylaxis are sparse. OBJECTIVE To investigate the incidence and clinical predictors of biphasic reactions in children presenting to the emergency department (ED) with anaphylaxis. METHODS A health records review of ED visits at 2 large Canadian academic pediatric EDs was conducted. All visits that satisfied anaphylaxis diagnostic criteria of the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network were included. Predictors of biphasic reaction were analyzed using univariate and multiple logistic regression analyses. RESULTS Of 1,749 ED records reviewed, 484 visits met the study inclusion criteria. Seventy-one patients (14.7%) developed biphasic reactions. The median age was 6 years (interquartile range 2.7-10.1) and 51 (71.8%) were boys. Forty-nine of the 71 (69%) delayed reactions involved respiratory and/or cardiovascular manifestations and 35 (49%) were treated with epinephrine. Five independent predictors for biphasic reactions were found: age 6 to 9 years (odds ratio [OR] 3.60, 95% confidence interval [CI] 1.5-8.58), delay in presentation to the ED longer than 90 minutes after the onset of the initial reaction (OR 2.58, 95% CI 1.47-4.53), wide pulse pressure at triage (OR 2.92, 95% CI 1.69-5.04), treatment of the initial reaction with more than 1 dose of epinephrine (OR 2.7, 95% CI 1.12-6.55), and administration of inhaled β-agonists in the ED (OR 2.39, 95% CI 1.24-4.62). CONCLUSION Biphasic reactions seem to be associated with the severity of the initial anaphylactic reactions. We identified clinical predictors that could ultimately be used to identify patients who would benefit from prolonged ED monitoring and enable better utilization of ED resources.
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Affiliation(s)
- Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Ian Stiell
- Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kevin Chan
- Memorial University and Eastern Health, St John's, Newfoundland, Canada
| | - Gina Neto
- Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Abdulaziz Alsadoon
- Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - George Wells
- Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Trendelenburg V, Enzian N, Bellach J, Schnadt S, Niggemann B, Beyer K. Detection of relevant amounts of cow's milk protein in non-pre-packed bakery products sold as cow's milk-free. Allergy 2015; 70:591-7. [PMID: 25653172 DOI: 10.1111/all.12588] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Currently, there is no mandatory labelling of allergens for non-pre-packed foods in the EU. Therefore, consumers with food allergy rely on voluntary information provided by the staff. The aim of this study was to characterize allergic reactions to non-pre-packed foods and to investigate whether staff in bakery shops were able to give advice regarding a safe product choice. METHODS Questionnaires were sent to 200 parents of children with a food allergy. Staff of 50 bakery shops were interviewed regarding selling non-pre-packed foods to food-allergic customers. Bakery products being recommended as 'cow's milk-free' were bought, and cow's milk protein levels were measured using ELISA. RESULTS A total of 104 of 200 questionnaires were returned. 25% of the children experienced an allergic reaction due to a non-pre-packed food from bakery shops and 20% from ice cream parlours. Sixty percent of the bakery staff reported serving food-allergic customers at least once a month, 24% once a week. Eighty four percent of the staff felt able to advise food-allergic consumers regarding a safe product choice. Seventy three 'cow's milk-free' products were sold in 44 bakery shops. Cow's milk could be detected in 43% of the bakery products, 21% contained >3 mg cow's milk protein per serving. CONCLUSION Staff in bakery shops felt confident about advising customers with food allergy. However, cow's milk was detectable in almost half of bakery products being sold as 'cow's milk-free'. Every fifth product contained quantities of cow's milk exceeding an amount where approximately 10% of cow's milk-allergic children will show clinical relevant symptoms.
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Affiliation(s)
- V. Trendelenburg
- Department of Pediatric Pneumology and Immunology; Charité Universitätsmedizin; Berlin Germany
| | - N. Enzian
- Department of Pediatric Pneumology and Immunology; Charité Universitätsmedizin; Berlin Germany
| | - J. Bellach
- Department of Pediatric Pneumology and Immunology; Charité Universitätsmedizin; Berlin Germany
| | - S. Schnadt
- German Allergy and Asthma Association; Mönchengladbach Germany
| | - B. Niggemann
- Department of Pediatric Pneumology and Immunology; Charité Universitätsmedizin; Berlin Germany
| | - K. Beyer
- Department of Pediatric Pneumology and Immunology; Charité Universitätsmedizin; Berlin Germany
- Icahn School of Medicine at Mount Sinai; New York NY USA
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